News and Views on Social Marketing and Social Change

11 posts categorized "eHealth"

Everyone has an opinion about the veracity, safety and privacy of health information on social network sites (SNS); now we have some data.

Investigators from the Children's Hospital Informatics Program evaluated the quality of health information on 10 social network sites (SNS) with an average membership of 6,707 that were organized around diabetes as the health concern. Among their findings were that only half of the SNS had content that aligned with clinical/evidence-based practice recommendations, while misinformation about a diabetes 'cure' was found on four moderated sites and three sites carried advertisements for unfounded cures (9/10 sites permitted advertising). Seven of the sites were hosted by for-profit entities and 3 belonged to professional organizations. In general, they found a high degree of variability in the quality and safety of the information provided on the sites, reports the American Medical News.

Their evaluation found privacy policies on 8/10 sites and on those sites they were within 2 clicks of the homepage. No policy was written at or below an 8th grade reading level (range 9.5.years - 18.4 years of education). The level of security to protect personal information was low - only one site used 2 of the three security indices and the rest used none or could not be determined. The security indices the researchers used were (a) privacy data storage using encrypted media, (b) data transmission through a secure socket layer, and (c) use of an external agent to audit security practices.

Overall, the results showed that the sites with the higher levels of alignment with diabetes science and clinical practice recommendations were most likely to have high levels of transparency and protection from misinformation. Only half of the sites were moderated, though this presence was not associated with less misleading information appearing on the site.

The report is valuable for, as the authors note, 47% of online adults in the US are engaging with SNS. This may be the first report to assess the quality and accuracy of the information published on these sites, as well as site privacy policies and practices.

"The phenomena [of social networking] itself in some ways is a big giant arrow pointing to some of the weaknesses, deficiencies or constraints on the traditional health care system and all its parts, whether it's patient education or advocacy or social support or effective communication" according to Elissa Weitzman, assistant professor of pediatrics at Harvard Medical School and lead author of the study that will appear in the Journal of the American Medical Informatics Association.

Based on the admittedly small sample of SNS, the authors urge patients, patient advocacy groups and medical communities to get involved with the oversight of online health communities. They recommend that sites:

• Identify where patients can get help and post guidelines for care. • Use credentialed moderators. • Enlist periodic external review of member discussions to protect users from misinformation and reinforce effective moderation. • Clearly flag commercial content and commercial members. • Ensure that privacy policies are easy to find and readable by the majority of healthcare consumers. • Provide for member control over sharing of personal health information. • Use industry standards to protect individual health information and sharing default settings that protect personal health information.

Thanks to Elissa Weitzman for a copy of the paper to verify and round out this report.

“We can reach and change the behavior of our target audience through social networking sites like Facebook and Twitter.”

This sentence captures the prevailing sentiment I find whenever two or more public health people gather to discuss their interest in social media and using it to advance public health goals. Notwithstanding the fact that their enthusiasm for these methods outpaces the development of an empirical literature to support their use, while also recognizing that the majority of US adults and teens are active users of these media, the sentence illustrates at least five misperceptions about the nature of social media and working in this space.

Fiction #1. We can reach audiences with social media

Many actors in the social media space, and this extends to users far beyond public health and the public sector, think of social media as another channel through which they can deliver messages to audiences. They view social media in much the same way that they have used broadcast and print media: as a tube through which they can deliver messages that will stick with and persuade people to change behaviors, purchase products or use services. They also greatly simplify the challenge, for example, by thinking of social media as consisting of only social network sites (SNS). As the chart Fred Cavazza created a few years ago shows, the social media landscape is more complex. Indeed, it is difficult to imagine that someone would undertake a television project believing that they can reach people by relying on CBS and FOX as their only outlets, but the analogy of using just Facebook and Twitter is lost on many.

Diving deeper into the Twitterverse - something Brian Solis and Jess3 have just mapped out - it is clear that each of the current social media darlings become even more complicated.

One reaction to all these opportunities is to be simply overwhelmed by them; and that's the point! Social media is not a new way to “reach” people - it is an 'attract and join' space. It is not a space with people sitting on a couch waiting to be entertained; this is a place where people actively seek out their own entertainment, and more importantly connect with their family, friends and people with whom they share similar interests.

The people we wish to engage with around specific issues need to be understood in the context of how they construct their social media space, not by how we construct it for ourselves. This idea became crystal clear to me during a project in which we were interviewing young, low-income women about their use of social media. Because we were already contemplating recruiting peer counselors, or evangelists, as part of a social marketing program to increase use of family planning services, we deliberately constructed focus groups consisting of women from this priority group who are currently enrolled in 2-year nursing or other health professional education programs. What we heard from these women was that they were now creating Facebook profiles because they felt they needed a more professional identity. These women had all been MySpace users and insisted they would continue being active there as well. Their comments solidified my POV, and reinforced what is reported by others and work being done on Personas at the MIT Media Lab: that many people use social media to create a variety of personas (I have a least 7 by their analysis). Most interesting in the research was the women's perception that having a Facebook profile signaled their transition into a new stage of their work life or career.

There are also circumstances in which public health people believe that there are groups who are not involved with social media. While there is some truth to this rumor, it is less veridical than many presume. The chart from the Pew Internet & American Life Project shows more than 50% of online adults between the ages of 18-55 use social network sites (SNS). More importantly, SNS are among the fastest growing online activities among 34-73 year-olds.

Fiction #2: We can change people with social media

This assumption is predicated on the idea that persuasive messages can be developed and delivered intact through social media to all of the people we wish to influence. This assumption often leads to the concern of "How do we ensure that our message is delivered as we want it to be?” Such people are used to the security of putting words onto a printed page, into a PDF format or a prerecorded radio or television spot where tampering with the message is designed out of the process. Indeed, the great leap that people must make when working with social media is designing content with the expectation that it will be passed on by others, perhaps edited or amplified, perhaps an opinion will be attached to it, mashed up with other content or even be responded to - rather than simply consumed.

Another underlying assumption is that people are active in social networks to learn things and are open to changing their behaviors. What we do know from surveys by the Pew Internet & American Life Project is that most people on the Internet are there to tap into their social networks. And people do not choose to be friends with people, or organizations, because of a promise that 'we are here to change you (or sell you something).' If we are to honor the notion that relationships through common interests are the basis on which social networks are developed, then we also must recognize that people on SNS are not looking for people to change them. To return to the 'attract and join' position, the early experiences we have using SNS for behavior change efforts in these networks and communities tend to attract like-minded people who are either looking for ways to support their own change efforts that are underway, or to discover resources they can use or to help others make the same change - for example, people who are attempting losing weight or who have quit smoking.

The third variable in the 'change' presumption is that it will occur through individual, or psychological, mechanisms. This perspective overlooks the value of working in the social media space: that is, directly addressing some of the social variables that influence behavior, as well as improving social connections and social capital in online communities. I've written quite a bit about social influences, social networks and health behaviors. My bottom line is that we are being forced by the explosion of social media to face the reality (and some might say - "again") that social networks frame the opportunities and constraints for change.

Fiction #3: Health behaviors are the focus of our social media efforts

Many people who undertake social media efforts targeted at behavior change assume that people interact with social media much like they do with broadcast media - that is, very little. People on social media sites are not sitting in front of a computer screen simply switching channels or adjusting the volume. They are reading news and updates from friends, searching for information, sharing with others, making new friends, rating products and services, tagging content, posting and uploading content, linking to content as well as retweeting it - to name just a few behaviors that will affect their ability, as well as ours, to effectively engage with each other for a common purpose of learning and acquiring new behaviors. Overlooking these component skills may be the greatest risk to public health programs that are delivered via social media.

To briefly illustrate this point, we must understand that segmentation is not just about the behaviors that are of interest to us, our organizations or society. Rather, we also need to include in our segmentation schemes the fact that there are social media behavioral segments that need to be incorporated into the design of our programs. For example, Forrester Research (2006) has identified six segments they label as Inactives (over half of US adult online users), Spectators, Joiners, Collectors, Critics and Creators.

Preece & Schneiderman (2009) have a similar behavioral segmentation scheme they call the “Reader-to-Leader Framework" which should be required reading for designers of behavior change programs in SNS or online communities. In their paper they give a number of both technological and social prompts that can help guide people through the process of moving from a Reader to a Contributor, Collaborator and Leader role.

What both of these segmentation strategies highlight is that many people who are on SNS or online health communities participate at very low levels of activity. This finding should make some people pause and question their assumption that behavior change through social media is simply presenting the right message, at the right time, to the right audience.

Fiction #4: We have target audiences who use social media

At a superficial level, this assertion it is true. However, the presumption that a target audience is waiting for us to reach, touch, engage them or otherwise treat them as passive consumers is a sure route to failure. As most people soon learn, in the social media space the targets can shoot back.

So it is little wonder that when organizations intend to use social media that much of the early planning centers around questions of how open the organization will be to comments and participation, whether and how to create content that people can modify - or not, whether to involve people formerly known as the audience as co-creators of content and whether to design program elements that allow people to actively reach out and engage people in their own social networks in the change process (that is, become extenders or evangelists for the cause).

Thinking of people in SNS or online communities as “target audiences” also fails to acknowledge that in the social media world it is not about audiences, but communities. I see this bias arise when agencies begin thinking about creating their own communities before understanding whether there might be existing online communities that they could join.

The most important opportunity that letting go of the “target audience” mindset provides us is that we can leverage and facilitate the interpersonal, or word-of-mouth, communication that naturally occurs in these networks and communities. If we approach social media without a “consumer” frame, we can then think about how we can utilize the most significant influencer for new learning and behavior change - interpersonal communication. Adopting this perspective makes it easier to understand why we have to let go of our content, unlock the formatting keys and make the content accessible to people who can then pass it along to others. (More on The consumer as participant rather than target audience - pdf).

Have you truly thought for all these years that people either heard or saw your content and said nothing to anyone else, or if they did repeated it perfectly? Only with the advent of social media, and the ability to experience these second- and third-hand transactions, does the question seem relevant. But that does not change the fact that people have been talking about our messages and content for years; we just weren't able to watch or hear it (maybe we just weren't interested - or now we think we can be held accountable for what they say).

Fiction #5: To use social media effectively we need to be on Facebook and Twitter

The prevailing wisdom is that using Facebook and Twitter are the keys to success in the social media world. In most cases, this presumption is based on the numbers of visitors that go to these sites rather than any understanding of whether our priority groups do or whether those sites are the best place to try and engage them in behavior change or community building activities.

It is also important not to rush past other Internet assets just to be part of the social media dance. As John Mack of Pharma Marketing Blog illustrated from a recent Accenture survey, social media sites are the ones health information seekers are least likely to visit - lagging behind online patient communities, pharma websites and general and medical websites such as Wikipedia and WebMD. This calls for carefully considering your objectives and the way your priority group uses the internet and SNS before jumping to the Facebook and Twitter default.

Decisions about where to focus your social media resources may also contribute to widening health awareness, information and status gaps among users who use the sites and those who don't. It is also well worth considering whether sites like Facebook deserve the attention of public health organizations at all. For example, when one looks at the groups of people most deserving of public resources, and among whom some health problems may be more prevalent, MySpace may be more important. danah boyd noted several years ago that 'MySpace has most of the kids who are socially ostracized at school because they are geeks, freaks, or queers.' MySpace has always been the habitat for people outside the mainstream and ignoring that fact, and that there are millions more of teens and adults like them in various ways, lends an urgency to getting answers to questions of 'how can we attract and join with people who hang out on SNS to promote and support more healthy choices in our everyday lives?'

Now that we have these five fictions on the table, what would you like to do next?

The great paradox for communicators and
marketers is that while we give rhetorical priority to concepts of
interactivity and audience-focused programs, we continue to hammer away
at “breaking through the clutter,” “capturing people’s attention” and
“getting people to do things.” Yet, even before the emergence of social
media the music was already echoing off the walls: It’s no longer about getting attention, it’s about earning it.

This presentation describes a scale for measuring the engagement properties of eHealth content that was adapted from commercial advertising research. Accompanying research suggests that a 9-item revised eHealth Engagement Scale is a robust tool to operationalize this concept across a variety of health topic areas. The eHealth Engagement Scale may prove to be an important mediator of user retention of information, intentions to change, and ultimately efforts to undertake and achieve behavior change.

There are many different ways to think about engagement. This scale begins to get at the consumer/user experience of engagement that we define as the process of involving users in health content in ways that motivate and lead to health behavior change.

'Increasing the engagement of people' with advertisements, brands, communities, issues and media gets thrown around by many, however, rarely do I see someone operationalize it beyond eyeballs and clicks.

From our scale:

Engagement = Involving + Credible + [not dull + hip, cool]

See the presentation for more details, including the path model, and I look forward to your comments!

I did find two quotes from the report worth pondering for how they might influence our work:

Mobile access is changing the behavior of internet users and, in particular, changing the behavior of health care consumers. The mobile internet draws people into conversations about health as much as online tools enable research.

…technology is not an end, but a means to accelerate the pace of discovery, widen social networks, and sharpen the questions someone might ask when they do get to talk to a health professional. Technology can help to enable the human connection in health care and the internet is turning up the information network’s volume.

I also was playing around with understanding the data in a more visual way than the charts and graphs in the report. Here is what I came up as the critical pieces of the puzzle - with the caveat that there are differences among demographic groups. But overall, the view from my POV and the data is this:

What this chart depicts are the percentage of Americans (note: not internet users) that report using different sources for health information. Health professionals (86%) are the most frequently reported ones, followed by friend or family member (68%); going online (57%); books or other print reference materials (54%); social media including blogs and social network sites (37%) and insurance providers (33%).

One of the difficulties I have with reporting data in this manner is that we do not get a dynamic picture of what sources of information people access FIRST and in what sequence. How do they go about solving the health challenge they are facing - whether it be symptoms they or a family member are experiencing, how to lose weight, which doctor or hospital to go to? And I am sure some health issues are approached differently than others. However, the authors of the report offer two snippets of information on page 16 that start bringing this dynamic into focus as it relates to online activities. As shown in the red and purple lines, once people have accessed information online, 66% report they are likely to discuss it with a friend or family member (red line), whereas only 'a handful' of people said that they discussed it with a health professional (purple one).

These two paths raise an interesting question about how people go about validating the health information they find on websites. And I am also willing to wager that health professionals, except in the cases of immediate needs and emergencies, are not the first place people go for their information. How the search and problem-solving process unfolds for different health issues needs to be looked at much more closely and with a full appreciation of the social network effects that are entwined in them. The data available in this report begin to articulate some of the contours we should be investigating.

When I first started using the term open source epidemiology to describe illness and disease surveillance systems that any one could contribute to, my focus was on wikis such as ProMED sponsored by the International Society for Infectious Diseases. Today, NYT coverage is focused on Google and their Flu Trends app [see also The Wall Street Journal].The idea is simple: Google scours their searches for entries like "flu symptoms" and then displays the results by state. The display page also has links to the CDC Home Page (bad idea, why not here?) and the Flu Shot Locator sponsored by the American Lung Association (great idea!). The reports today note that flu outbreaks using this search strategy on consumer-generated data may detect flu outbreaks 7-10 days before the CDC reports them using their traditional methods such as emergency room visits. In terms of timing and early warning systems think about that: monitor people searching for flu symptoms and how to treat them or wait until they show up at the already overburdened ERs when all else has failed. From Miguel Helft's reporting in the NYT.

Google Flu Trends avoids privacy pitfalls by relying only on
aggregated data that cannot be traced to individual searchers. To
develop the service, Google’s engineers devised a basket of keywords
and phrases related to the flu, including thermometer, flu symptoms, muscle aches, chest congestion, and many others.

Google
then dug into its database, extracted five years of data on those
queries and mapped it onto the C.D.C.’s reports of influenzalike
illness. Google found a strong correlation between its data and the
reports from the agency, which advised it on the development of the new
service.

Try this analogy with your colleagues to make the point about social media and public health: the amber alert program for missing children is not created and acted upon by just law enforcement agents. They use citizen reports and all forms of media including cell phones and widgets, to mobilize communities to search for and safely recover missing children. Seems like an easy model for pandemic flu preparedness - though devilish in the details (they tell me. I am not convinced. Sometimes the issues lie in getting you to try and answer the wrong questions).

When confronted with some of life's common problems, more people rely on the internet for information and support than they do on experts or family members.

The report from the Pew Internet and American Life Project finds that 76% of US adults have access to the internet, a figure that has shown little change over the past 2 years. Likewise, broadband access (reported by 77% of all users or 55% of all American adults) remains a major determinant for how often people access the internet, the variety of reasons they do so, and the richness of the experience while they are on it. Persons with only dial-up access to the internet at home (what they refer to as low access) were more likely to have household incomes < $40K, have a high school diploma or less and be age 62 years or older.

In the study, 45% (n=756) of the sample reported they had dealt with a serious illness or other health condition experienced by either themselves or someone close to them in the past two years - the most common of the ten problems asked about. In coping with health problems, the sources of information were quite different from the overall picture. People looking for information and support for a health problem were most likely to consult a health professional (86%) followed by family or friends (51%), the internet (46%), print sources (37%), TV or radio (17%) and government agencies (16%).

These data need to put into context with other research by the Pew Internet Project that has found, for example, that 80% of all US adult internet users have searched for health information on the web. While searching for health information may be an activity that engages a majority of people at some point in time, when a health situation arises health information seeking becomes a high involvement behavior that may be aimed at reducing social distance and facilitating social support. However, it is also the case that the internet has surpassed all other media - other than interpersonal - as the preferred channel for health information for adults who have access to it.

36% said the internet helped them find advice or support from other people.

34% said the internet helped them find professional or expert services.

26% said the internet helped them find information or compare options.

Whether casually searching for health information, seeking it because of a health problem, or coping with the illness of someone, the internet has become a dominant part of the communication network people prefer to access. Equity of access, especially among people with no or low access, must continue to be an on-going policy concern as more Americans look to the internet for understanding and addressing their health care needs.

Up to 30 percent of South Koreans under 18, or about 2.4 million
people, are at risk of Internet addiction... They spend
at least two hours a day online, usually playing games or chatting. Of
those, up to a quarter million probably show signs of actual addiction,
like an inability to stop themselves from using computers, rising
levels of tolerance that drive them to seek ever longer sessions
online, and withdrawal symptoms like anger and craving when prevented
from logging on.

To address the problem, the government has
built a network of 140 Internet-addiction counseling centers, in
addition to treatment programs at almost 100 hospitals and, most
recently, the Internet Rescue camp, which started this summer.
Researchers have developed a checklist for diagnosing the addiction and
determining its severity, the K-Scale. - NYT, Sunday, 18 Nov.

They find that while more US adults go online for health information, 52% are still ambivalent about doing so. The segments they identify include:

Senior Hopefuls (15% of the market or 13.1 million) - don't currently go online, but would consider it if Web sites were simpler to or a caregiver or gatekeeper searched for them.

Trusted Challenged (11% or 9.6 million) - a group that routinely goes online, but doesn't look for online health-related information because they question its credibility.

Gatekeeper Users (12% or 10.5 million) - are not confident using the Web on their own, so they have friends and/or family do it for them.

Old School (9% or roughly 7.8 million seniors) - are considered largely unreachable for marketers via the Internet. This group doesn't go online and believes there is no reason to use the Web.

The researchers point to the advantage of targeting caregivers or gatekeepers as a leverage point for bridging that gap between positive intentions and seeking health information online for oneself. Digital divides continue to narrow for having the technology and the desire to use the internet as a health information resource among the mature market. Yet, having the digital health literacy skills (including being able to filter credible content in searches and then understand and act on it) will be an on-going and growing concern for public health policy.

Health care revolves around information. Historically, the centers of gravity were priests and shamans (now referred to as 'indigenous healers'). Over the past century MDs and medical researchers have been the culturally sanctioned repositories and dispensers of such knowledge. A more recent evolution of the health care information space has been the more frequent appearance of the everyday person (aka consumer or patient) as a key actor. The emergence of the everyday health information specialist is powered by the internet - both as a compilation of information previously received and shared only among the health elites and by its capacity to quickly and relatively easily deliver information more-or-less tailored to an individual's search query [whether and how people can develop effective search queries is another matter altogether.]

The competition to get into the health information space is enormous. Every health encounter includes the search for, or exchange of, health information (how do I stay healthy, is this a symptom of a problem, who should I see about it, how do I diagnose it - explain it to my patient, what are the treatment options, who will pay for it?). Over the years, various types of health and medical information sites have been created to 'put' information from various sources into one place. However, the capabilities of newer search engines with more powerful and personalized capabilities casts into question whether these clearinghouse strategies will have any relevance (attract users) even 2-3 years from now unless they develop and deliver a value to users that goes beyond answering 'information please?'

The Medstory purchase, said Peter Neupert, vice president for health strategy at Microsoft, was a first step in a broader company strategy to assemble technologies that would “improve the consumer experience in health care.”

“Clearly,” Mr. Neupert said, “search is a critical part of that better end-to-end experience for consumers.”

Designing consumer experiences around the search process has to begin with the premise that we are in a problem-solving scenario that occurs multiple times in the course of changing health behaviors or screening, diagnosing, treating, recovering, providing care and living with medical diseases and conditions. How do we deliver a search experience that helps people solve problems, not just understand them? That's a fundamental challenge for all health information providers. As new players come into the health space, expect to see some disruptions in how health information and health care are thought about and approached when the consumer experience is the center of attention and not the interests and convenience of the providers and infrastructure.

The great paradox for communicators and marketers is that while we give rhetorical priority to concepts of interactivity and audience-focused programs, we continue to hammer away at “breaking through the clutter,” “capturing people’s attention” and “getting people to do things.” Yet, even before the emergence of social media the music was already echoing off the walls: It’s no longer about getting attention, it’s about earning it.

Developing and testing a model for presenting health information using various outcome measures.

Exploring how to measure engagement of users with the content. Our ultimate goal here is to establish a set of measures that can then be used to test various usability, design and social media approaches that will enhance user experiences on the site and increase their likelihood of trying new health behaviors – or using the information in their interactions with family and friends who want to change their own behavior.

If you are familiar with the engagement measurement initiative of the Advertising Research Foundation, that is not what we are doing in terms of brand encounters (though there may be some applicable lessons). Rather, we are interested in measuring the level of involvement and interaction a user has with health content (in this case presented as pages on a website) as an intervening variable in the behavior change process. A working hypothesis is: the more engagement a user has with health content, the more likely s/he is to:

Recommend the site to others

Return for follow-up visits

Bookmark or tag the relevant pages

Contribute content to the site via rating pages, making recommendations, post comments, etc

Find the content appropriate, acceptable and applicable for themselves and the problem they are looking for information on

Report feeling more prepared, confident and inclined to change a health behavior

Try new health behaviors

Maintain those behaviors

We used an initial pool of 12 items to measure engagement. Of these items, the ones that asked how clever, suspenseful, and absorbing content was accounted for the most number of significant differences among demographic groups for one or more of the 9 health topics we investigated. These items all seem to reflect an underlying dimension that reflects the attentive (or “involving”) properties of the materials (although the specific item attention-grabbing was only rated differently by groups in two instances—once in association with clever and in the other with surprising). Thought-provoking,stimulating, and convincing were the other items that we also found distinguished between groups on at least two occasions.

SO what? Well, we seem to have found a way allow people to discriminate how engaging they find health content. Our initial findings that different groups of people find some content more engaging than other groups (for instance, older adults find information about high blood pressure management more engaging than younger adults) is, on the one hand, intuitive. Yet, the implications are we may now use this measure of engagement to actually see how changes in content, layout, language, navigation and interactivity affect the illusive ‘engagement’ our audience has given us, and how to deepen this effect to enable positive impacts on their lives and further our health and social goals. Calibrating our content - whether it be presented aurally, tactually or visually, though print, electronic or digital media – to maximize it’s ability to engage people once they are open to it is the next big step for communicators and marketers.

How to engage your audience? Start with presenting information in clever, unexpected ways that raises a question or poses a problem the audience is interested in solving. It all goes back to being relevant to their lives [pdf], not ours.

Every meeting I am in to discuss how to address the obesity problem among children and teens inevitably touches on the issue of preventing untoward effects - namely, increasing the prevalence of eating disorders. The concern is motivated, in no small part, by the difficulty of identifying, motivating and treating people who are bulimic or anorexic. Another concern is whether teens at high risk for developing an eating disorder will perceive messages and programs focused on preventing weight gain or promoting weight loss as more reasons to 'race to the bottom.'

The Washington Post highlights an Internet-based treatment program for high-risk women: Student Bodies. While a program like this is not a panacea for the possible negative effects of national weight loss initiatives, it is designed as a prevention program for high risk women that might provide a model for adjunctive products and services in a comprehensive weight education effort directed at tweens and teens.

"This study is a very significant piece of research because it
demonstrates that one can transfer what's known about risk factors into
a program that can be applied at very low cost," said Michael Levine,
an eating disorders expert who is a professor of psychology at Kenyon
College in Ohio. "And it gives every indication of being able to reduce
important risk factors" for eating disorders such as excessive concern
about body image and weight.

For social marketers and public health educators, eHealth tools offer the ability to provide tailored interventions to very specific segments of the population. The potential promise of these interventions is that they can provide greater access to evidence-based interventions at reduced costs for both providers and users. As has been pointed out by others, an effective intervention that can reach large numbers of people, even if it has only a moderate effect size (in terms of changing behaviors), can achieve a substantial public health impact.

The report also notes the importance of employing five criteria (the 5As) in evaluating eHealth tools:

Access. Large numbers of eHealth tools have been developed, but it is not known how many people know about these tools, how many are using these tools outside of research studies and closed health care systems, and how many may be willing to try them.

Availability. Many of the studies utilized convenience samples or required computer ownership. This approach has led to a disproportionate amount of information on Caucasian women with higher education levels. The lack of diversity in the research samples and limited evidence indicating differential effects based on demographics suggest major gaps in knowledge.

Appropriateness. Some tools have been developed that target special populations, and some of these were developed with input from the target audience. These studies show that with careful attention to cultural, literacy, and technological needs, successful tools can be developed for and used by diverse groups.

Acceptability. People like eHealth tools and generally find them easy to use. Although usage seemed to decline over time, the declines were not as steep as those found in the control conditions.

Applicability. Many studies found positive changes in knowledge and intention after just one interaction using eHealth tools. Findings on actual behavior change and health outcomes have been less clear. However, many of these studies may not have provided interventions with enough frequency or intensity to bring about desired changes in these areas, or they may not have used appropriate control groups. Many studies relied on self-reported data to document change.

There is a clear need for developers of these eHealth tools and social marketers to get together for public health change. As yet, I am not familiar with efforts to take these eHealth tools, predominantly created and tested in academic settings, to scale. Clearly it is incumbent upon the sponsors of these research programs, and the grant recipients, to factor in the costs of marketing effective programs and fund them - whether as continuation grants or as a new type of dissemination grant - to fully realize the contributions of this research and eHealth approaches to improving the public health.